Healthcare Provider Details

I. General information

NPI: 1336150960
Provider Name (Legal Business Name): WESTSIDE BOUTIQUE PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 06/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7643 N SAN FERNANDO RD
BURBANK CA
91505-1073
US

IV. Provider business mailing address

PO BOX 5063
GLENDALE CA
91221-1063
US

V. Phone/Fax

Practice location:
  • Phone: 818-504-6444
  • Fax: 818-504-6441
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY45059
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SEVAK OLMESSEKIAN
Title or Position: PHARMACIST IN CHARGE
Credential:
Phone: 323-533-5516